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CHEESY METAMORPHOSIS (TUBERCLE, CANCER). 479
The cheesy transformation is the regular termination of tubercle, but, on the one hand, it is not the necessary one, inasmuch as there are rare cases, in which tubercles, in consequence of their undergoing a complete fatty metamorphosis, become capable of reabsorption; and, on the other hand, the same cheesy metamorphosis befalls other kinds of cellular new-formations; for pus may become cheesy, and likewise cancer and sarcoma. This metamorphosis, therefore, being common to more than one formation, cannot well be set down as a criterion for the diagnosis of any particular structure, such as tubercle; on the contrary, there are certain stages in its retrograde metamorphosis, where one cannot help confessing that it is not always possible to come to a decision. If a lung be laid before you with cheesy masses scattered through it, and you are asked if that be tubercle or no, you will frequently be unable to say with certainty what the individual masses originally were. There are periods in the course of development, when that which is inflammatory and that which is tuberculous can with precision be distinguished from one another; but, at last, there comes a time, when both products become confounded, and when, if one does not know how the whole arose, no opinion can any longer be formed as to what its nature is. In the midst of cancerous masses also cheesy spots occur which look exactly like tubercles. I have demonstrated that it is by the gradual transformation of the elements of cancer that this cheesy matter is produced. But if we did not positively know from the history of their development that cancer-cells disintegrate step by step and that no tubercles form in the middle of cancer, we should in many cases be altogether unable to arrive at any decision from merely examining the specimen.
If these difficulties be surmounted which lie in the external appearance of the formation, and lead the observer astray not only when he considers its grosser features, but also when he investigates its more intimate composition, there remains nothing else to assist as in coming to a right conclusion than the investigation of the type of development displayed by the individual new-formations during the stages of their actual development, not during those of their retrograde metamorphosis. The nature of tubercle cannot be studied after the period, when it becomes cheesy, for from that time its history is identical with the history of pus which is becoming cheesy; an earlier period must be chosen when it is really engaged in proliferation. So in the case of other formations, that period must be studied which is comprised between their origin and their culminating point, and we must see with what normal physiological types they agree. Then it is, I think, certainly possible for us to arrive at a just conclusion with the aid of the simple principles of histological classification, which I have already propounded to you (p. 63). Heterologous tissues also have physiological types.
A colloid growth, if we really take it to mean what Lacnnec did—a gelatinous organized new-formation—must necessarily correspond to some type to be met with in the body when in its normal condition. Thus there are a series of tumours, that have been included in the colloid class, which have altogether the structure of the umbilical cord and which, like this part, essentially contain mucus in their intercellular substance. Now since I had named the tissue of the umbilical cord and analogous parts, mucous tissue, it was a very simple step for me to call these tumours Mucous tumours (Schleimgeschwiilste), Myxomata. When we demonstrate the occurrence of tumours exhibiting the histological type of the umbilical cord in the midst of the adult body, the striking character of the phenomenon is in no wise lessened, but we have found for them a type among the normal tissues of the body. Another form of LYMPHOID NATURE OF TUBERCLE. 481
colloid, or as Johannes Muller has called it, Collonema, turns out to be merely cedematous connective tissue. We find nothing more than a very soft tissue, soaked in an albuminous fluid. Such a tumour cannot be separated from connective-tissue (fibrous) tumours generally, whether they be denominated gelatinous, cedematous, or sclerematous1 connective-tissue tumours, and I think there is no occasion to estrange it from the mind by bestowing upon it the name of collonema. So, again, we find certain forms of cancer, in which the stroma, instead of being composed simply of connective tissue, consists of the same mucous tissue which we meet with in a simple mucous tumour. These we may simply name Mucous Cancer (Gelatinous or Colloid Cancer). We then know exactly what we have before us. We know it is a cancer, but that its stroma differs in its containing mucus and in its gelatinous nature from the ordinary stroma of cancers.
To revert once more to the consideration of tubercle— it would certainly be something completely abnormal if it were composed of corpuscules tuberculeux; but if you compare the cells which are, as at least I must assume to be the case, the real constituents of the granule, with normal tissues of the body, you will remark the most complete correspondence between them and the corpuscles of the lymphatic glands, and this is a correspondence which is neither accidental nor unimportant, for was it not known even of old, that lymphatic glands have an especial tendency to undergo the cheesy degeneration! Even the old writers have stated that a lymphatic constitution disposes to processes of this kind.
With regard to pus, I need only remind you that we have been occupied during several lectures in discussing the question of the possibility of diagnosing between pyaemia and leucocytosis, and that we have recognized in the colourless corpuscles of the blood bodies so perfectly analogous to pus-corpuscles, that some have thought they saw pus when they had colourless blood-corpuscles before them, whilst Addison and Zimmermann, on the contrary, imagined they had found colourless blood-corpuscles where they really were looking upon pus. Both have a like type of formation. It may therefore be said that pus has a hatmntoid form, nay, the old doctrine may be revived afresh, namely, that pus is the blood of pathology. But if one would seek a distinction, if one would be able to say in individual cases what is pus and what blood-corpuscles, there is no other criterion than to determine whether the cell arose at a spot where a colourless blood-corpuscle might be expected to arise, or at one where it ought not to be produced.
1 Sclerema zz oedema durum.
So, moreover, we find amongst pathological newformations a large category, the natural type of which is epithelium—Epitheliomata, if you will. But the term epithelioma, which has recently been introduced by Hannover, is completely inadmissible in the case of the particular kind of tumour which it was intended to designate, because the epithelioma is by no means the only tumour whose elements bear the character of epithelial cells. Epithelioma cannot be distinguished from other tumours by its elements' having the character of epithelium whilst those of the others have it not. The tumour that (Johannes) M uller called Cholesteatoma, Cruveilhier, tumeur perlee— which I have translated Perlgeschwulst [pearly tumour]— this tumour has exactly the same epithelial structure as that which Hannover has called epithelioma, nay, ordinary epithelioma very commonly engenders in itself little pearly globules in an often astonishingly great number. Yet both exhibit very essential points of difference. Never as yet have any pearly tumours been seen which, after existing in one place, recurred in remote places, and be
haved like occur than
tumours; never did anything else a slight extension—and that at an extremely slow rate—to the immediate neighbourhood of the tumour. In the case of epitheliomata on the other hand, or as they
are otherwise called, epithelial cancer or cancroid, we see
Fig. 141. Solid mass of cancroid from a tumour of the underlip. Closely packed layers of cells at the circumference, presenting all the characters of the rele Malpighii; in one of the processes, globules glistening like fat; in t he middle of the body of the growth, a horny, cpidermoidiil, hair-like structure, with onion-like globules (pearls, globes epidcrmiques). 300 diameters.